WI0600126_DEEMED FILES_20190327

Permit Number
Program Category
Ground Water
Permit Type
WI0600126
Injection Heating/Cooling Water Return Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Gary Weyant and Janet Glasser SFR
Location Address
Vista Ln
Lot 175 Chalks Landing SD Phase 4
Rockingham NC
Owner
Owner Name
Gary
Dates/Events
Orig Issue
10/31/2013
App Received
Regulated Activities
Heat Pump Injection
Outfall
Waterbody Name
28379
Weyant
Draft Initiated
Scheduled
Issuance
Central Files: APS SWP
3/27/2019
Permit Tracking Slip
Status
In review
Version
Project Type
Renewal
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Gary Weyant
120 Vanita Dr
Moon Twp
Region
Fayetteville
County
Richmond
PA 15108
Public Notice Issue Effective Expiration
Requested /Received Events
Administrative amendment request received
RO staff report requested
RO staff report received
Streamlndex Number Current Class
2/25/19
2/26/19
3/25/19
Subbasin
Nortb-Carollna it partment of Environmental Quality — Division of Water Resources
NOTII*AklONI 7F INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
T 64g110 i4' `permitted by rule" and do not require an individual permit when constructed in accordance
with the rutei oNtit 02C.02'00 (NOTE: This form must be received at least 14 DAYS prior to iniectionl
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IIV SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C _0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a Iand surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of sail or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: March 14 _ , 2019 PERMIT NO. w tote 0 S C (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1) x Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) Passive Injection System Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) Tracer Injection Well Complete sections B thraugb N
STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign an behalf of the business or agency:
Narne(s): NCDEO/DWM/UST Section/Trust Fund Brand: Incident Manager- Herbert Bereer
Mailing Address: 1646 Mail Service Center.
City: Raleigh State: NC Zip Code:27699 County: Wake
Day Tele No.: 919-707-8170 Ce1I No.:
EMAIL Address: Herbert.Bercerg;nedenr.cov Fax No.:
Deemed Permitted OW Remediation NOI Rev. 3-21-2018 Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: --~P=---ca=tn=·=ck=-=L=u=eb=b=e=rt-=----------------------------
Company Name ________________________________ _
Mailing Address: -----=1-=1-'-4-=-0 -=B=lu=e=--gr=as=s""'L=an=e ______________________ _
City: Pinnacle State: _NC_ Zip Code: 27043 County: Stokes
Day Tele No.: ---~3""'3~6~-3~5-=l~-2~1~4~7 ____ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Lyn dal Butler
CompanyName -----'S=&=M=E~In=c=·-------------------------
Mailing Address: --~8~64~6~W~e=s~t M~ar=k=e~t =S=tr~ee~t~Su=i=te~1~0~5 ________________ _
City: Greensboro State: _NC_ Zip Code:27409 County: Guilford
Day Tele No.: ---=33c;6c...::-2=8=-8---"-7-=18=0'----------Cell No.: 336-312-0276
EMAIL Address: __ ~l=b--=u=tl=er=®=sm=ein=c=.c=o=m=-----Fax No.: ___________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ---~In=c=id~e=n~t #=3~5~l~0~N--'am=e~:--'N~ee=dh=am=s~S~e~rvi=· c=e~S~ta=tio=n~------
708 East Main Street
City: ---=P-=il=o'-'-t =M=o'--"un=ta=in,=___ ______ County-'--': S=u=ny::...,.... ___ --'Zip Code: ___ 2_7_04_1 _
(2) Geographic Coordinates: Latitude**: ___ 0 --__
11 or 36.3825 ° ___ _
Longitude**: 0 __ ,, or -80.4533 ° ___ _
Reference Datum: _______ ~Accuracy: ________ _
Method of Collection:_G~o~o~g~le~E_arth---'-------------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume:. ____ square feet
Land surface area of inj. well network: square feet~ 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated:_ (must be :S 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Pennitted GW Remediation NOi Rev. 3-21-2018 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved irifectants can be found online at h ttp ://deg.nc.gov/about/divisions/water-
resources/water-resources-p ermits/wastewater-branch/1!round-water-protection/ground-water-a pproved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: --------------------------------
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants:
Injectant: ----------------------------------
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant:
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: ----=l ___ Proposed __ ---=-1 ___ .Existing (provide GW-ls)
For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
( c) Well contractor name and certification number
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page3
L. SCHEDULES — Briefly deseribe the schedule for well construction and injection activities.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
WeII Owner/Applicant: "I hereby cert5, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true; accurate and
complete_ I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information_ I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well ll and all related appurtenances in accordance with the I SA NCAC 02C 0200 Rules."
Linda' Butler: Environmental Scientist, S&ME. Inc_ (Agent for NCDE1 1
Signature of Applicant Print or Type Full Name and Title
Proper'\Owner (if the properly is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200 , "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached Site Access Agreement signed by Patrick Luebbert dated February 21, 2019.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
"An access agreement between the applicant and property owner may be submitted in lieu of a signature on this, form.
Please send 1 (one) hard color copy of his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — ULC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediatyon NOI Rey. 3-21-201 s Page 4

TABLE 2
SUMMARY OF GROUND WATER ELEVATION DATA
NEEDHAM'S SERVICE STATION
JANUARY 17, 2005
{ ^' �' .
i- . k?T 0-.7.
' d
9 L •G 1 12�' :
�2 _ 5^' `1
-te ` k
� f1r ,-JiY'-':?�
'",--
* %� �SY •
f=
&JY
[ '" .
i "L'h4F1.
•-
�-
?F Sg, '-+r
4- .ma'
' .ii .— L
.
MW—IR
100.00
35.48
64.52
50
35-50
__
MW-3
100.32
331,95
68.37
54
'W'"1 y�}'y�j
jy'
�'•'[
x3�6..5-5!4yy
Tn. A
..iv:
MW-6R
101.36
38.98
62.38
50
35-50
• ,. _ 9 J J_ -'y r
•'1.-.2 �F .. �h• V' .i
,a• �i '•i
�a .. :ti=: ,;�
iSfi b [i.7- . ;+-� �a
', T. �nd- ..:_ •xi
'
1.a`,'
+� f y,
F;,,c S o' —
-
•
';•..
_- Avg
•x 7"u
s
MW-8
101.28
40.55µ
60.73
52
42-52
MW-10
98.80
37.44c
61,36
45
30-45
Notes;
1. Ground water elevations relative to a temporary benchmark with an assumed datum of 100.00 feet; data
reported in feet.
2. Not measured.
ANW-2 Sa-aszn nto-ir
6Q-o Lie11 C0 r15 fro4i J mn
-- 12.1\m4nfeN t 1—'041 �G,het�
1 con-t P kNNN
Slk
L u;dn5
'45177;14 0iNCn crown
MAR 18ZO3
rvm.t ctoarn

1000 MWiI
995
990
985
990
975
970
960
gay
930
T
CROSS - SECTION A
MWZ
MW-5
C;v : •��{,Y.: r.:
��rio,. bdB:Ab■ 'oap�
�.. b er [�q a• d' • 9
- o,i7n r `❑ ■nr )ep�' �■iJ ■ cQ g4e
�y
d y,
^�cr D• •4►.j`� .,° ��i.■ a.e..•.�,^J. rkpil
n$oQaQ�P?ri..P��' q a' Oa.QovauC�
e c
t`1 C• � •t �. .o
LEGEND
L
Li, SILT, SANDY TO TRACE SAND, MICA AND OUARTZ SRAVEL IN
SOME AREAL LAYERED, REDDISH-RRaWN TO MOTTLED,
FJRM TO STIFF.
M FINE SaNA, SILTY, GRAVELLY TO TRACE GRAVEL, LITTLE
MICA, MOTTLED, LAYERED, FIRM.
WEATHERED QUARTZ MCA SCHIST
BEDROCK S QUARTZ MICA SCHIST }
HORIZONTAL SCALE: ! = IS,fi
VERTICAL SCALE: I"= a.9'
NOTE: THE FLOATING PRODUCT EXTENDS
TO WELL 3 IN A VERY THIN LAYER.
FIGURE 5

Herb Berger
Hydrogeologist
DWM UST Section
1'646 Mail Service Center
Raleigh, NC 27699-1646
RE: Needham Service Station
708 East Main Street
Pilot Mountain, Surry County NC
Incident # 3510
Dear Mr. Berger:
Rael!•
MAR ~9 ._,
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environment and Natural Resources (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G.S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have fuU right of access during the period of the investigation.
4. An.y claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with North Carolina C.S. 132-1.
6, The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the land owner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
n14)e0--
Type/Print Name of Owner or Agent
3 /-, �/
Phone Num
et) _Biak iA)
y_o_s/Lte5- 0/5
City/State/Zip Code
A/17
Dale
V,Z/
Herb Berger
UST Section
Division of Waste Management
1646 Mail Service Center
Raleigh, NC 27699-1646

» On Jan 28, 2014, at 3:10 PM, "Rogers, Michael"
<[e-mail]> wrote:
» Janet-
>>
» Would you please send me a copy of the well construction record
(GW-1) for the geothermal well (I assume it has been built). This is
the form completed and signed by the driller showing as -built
construction. You can send as attachment in reply to this email.
Thanks.
» Original Message
» From: Janet [mailto:[e-mail]]
» Sent: Thursday, October 24, 2013 10:34 AM
» To: Rogers, Michael
» Cc: Barber, Jim; Barnhardt, Art
» Subject: Re: weyant glasser permits.pdf WI0600126
» Mr. Rogers,
» I understand and thank you for the estimated timeline.
» Janet
» Sent from my iPad
»> On Oct 24, 2013, at 9:55 AM, "Rogers, Michael"
<[e-mail]> wrote:
»>
»> If I can get the report by Friday and there are no issues, I will
get the permit to my supervisor for her review and signature Monday.
I will ask her to expedite and ask her to sign by the middle of next
week. I cannot make any promises, but I think the permit to inject
can be issued by the middle of next week; but if not mid -week, by the
end of the week.
»>
»> Thanks
>>>
»> Original Message
»> From: Janet [mailto:[e-mail]]
»> Sent: Thursday, October 24, 2013 9:12 AM
»> To: Barber, Jim
»> Cc: Barnhardt, Art; Rogers, Michael
»> Subject: Re: weyant glasser permits.pdf WI0600126
2

Rogers, Michael
From: Rogers, Michael
Sent: Thursday, January 30, 2014 1:08 PM
To: 'Janet'
Cc: Barber, Jim
Subject: RE: weyant glasser permits.pdf W10600126
The permit doesn't expire until 9/30/2018. Please let the regional
office know a couple of days prior to when you actually install the
well. Contact info is in your permit. Thanks.
Original Message
From: Janet [mailto:[e-mail]]
Sent: Wednesday, January 29, 2014 6:33 PM
To: Rogers, Michael
Subject: Re: weyant glasser permits.pdf WI0600126
Yes, we will install.
The bank took much longer than even they expected. Is there a
deadline or expiration on the permit?
Sent from my iPhone
> On Jan 29, 2014, at 12:27 PM, "Rogers, Michael"
<[e-mail]> wrote:
> Do you still have plans on installing? If not we can rescind your
permit if you request.
> Thanks
> Original Message
> From: Janet [mailto:[e-mail]]
> Sent: Tuesday, January 28, 2014 5:29 PM
> To: Rogers, Michael
> Cc: Barber, Jim; Barnhardt, Art; [e-mail]
> Subject: Re: weyant glasser permits.pdf WI0600126
> Mr. Rogers,
> The well has not been built yet.
> Janet
> Sent from my iPad
1